NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Sample Answer for NURS 6512 Week 9: Assessment of Cognition and the Neurologic System Included After Question
A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.
An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.
This week, you will explore methods for assessing the cognition and the neurologic system.
Learning Objectives
Students will:
- Evaluate abnormal neurological symptoms
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
Photo Credit: Kurt Drubbel/E+/Getty Images
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 5, “Mental Status” (64-78)
This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.
- Chapter 22, “Neurologic System” (pp. 544-580)
The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 4, “Affective Changes” (pp. 33-46)
This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.
- Chapter 9, “Confusion in Older Adults” (pp. 97-109)
This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history, as well as what to look for in a physical examination.
- Chapter 13, “Dizziness” (pp. 148-157)
Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.
- Chapter 19, “Headache” (pp. 221-234)
The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.
- Chapter 28, “Sleep Problems” (pp. 345–355)
In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”; p. 29)
- Chapter 4, “Pediatric Preventative Care Visits” (” Neurological Reflexes That Should Be Tested During Infancy”; (p. 108)
- Chapter 9, “Prescription Writing and Electronic Prescribing” (pp. 195-206)
Note: Download and review these Adult Examination Checklists and Physical Exam Summary to use during your practice neurological examination.
Bearden, S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.
This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.
Athilingam, P., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127
Retrieved from the Walden Library Databases.
Sinclair, A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001
Retrieved from the Walden Library Databases.
Required Media
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 5 and 22 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 14, “The Neurologic Examination” (pp. 683–765)
This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.
- Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)
In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.
Discussion: Assessing Neurological Symptoms
Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the Episodic/Focused SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
Case 1: Headaches
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
Case 2: Numbness and Pain
A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.
Case 3: Drooping of Face
A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.
To prepare:
With regard to the case study you were assigned:
- Review this week’s Learning Resources, and consider the insights they provide about the case study.
- Consider what history would be necessary to collect from the patient in the case study you were assigned.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 9”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
Submission and Grading Information
Grading Criteria
Post by Day 3 and Respond by Day 6
To participate in this Discussion:
NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Assignment (Optional): Practice Assessment: Neurological Examination
Short of opening a patient’s cranium or requesting a brain scan, what can an advanced practice nurse do to determine the cause of neurological symptoms? A multitude of techniques can be used to generate a neurological diagnosis.
In preparation for the Head-to-Toe Physical Assessment Video due in Week 10, it is recommended that you practice performing a neurological examination this week.
Note: This is an optional practice physical assessment. You do not have to capture a video of this assessment, as no submission is required.
To prepare:
- Arrange an appropriate time and setting with your volunteer “patient” to perform a neurological examination.
- Download and review the Neurological Checklist provided in this week’s Learning Resources.
- Ensure that you have a plexor (reflex hammer) to perform the examination.
To complete:
- Perform the neurological examination. Be sure to cover all of the areas listed in the checklist and to use the plexor appropriately.
Looking Ahead: Head-to-Toe Physical Assessment Video
In Week 10, you will videotape yourself conducting a head-to-toe physical assessment.
By Day 7 of Week 10
This video is due. Refer to Week 10 for additional guidance.
Week in Review
This week, you properly applied the assessment techniques and diagnoses for cognition and the neurological system. In addition, you evaluated abnormal neurological symptoms and explained which physical exams and diagnostic tests would render the appropriate results needed to make a diagnosis.
Next week, you will explore how to assess problems with the breasts, genitalia, rectum, and prostate while making the patient feel safe, listened to and cared about using a non-invasive approach.
A Sample Answer For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
Initials: JS Age: 20 Sex: Male Race: Caucasian
CC (chief complaint): Headache
HPI: JS is a 20 year old Caucasian male who presents today with intermittent headaches. The headaches diffuse all over the head, but patient states the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbone, and jaw. He rates the pain as a 6/10 and states he has had headaches for around 2 weeks now. JS states he takes two Tylenol 325 mg when he has the headaches and this helps him somewhat. Patient states these headaches make it difficult for him to concentrate at work and at school.
Current Medications: Tylenol 325 mg- takes 2 about every 6 hours as needed.
Allergies: PCN
PMHx: Up to date on all shots, flu shot last year 10/18, childhood history of asthma and ear infections
Soc Hx: Works as a server at local restaurant while attending school at the university full time. Denies current or previous tobacco and alcohol use. Uses his cell phone frequently but does not use it while driving.
Fam Hx: Mother- HTN, Asthma, Father- denies medical history, does not know medical history of grandparents.
ROS:
GENERAL: Denies weight loss, fever, fatigue, sweats, or chills.
HEENT: Head: headaches for the last 2 weeks, Eyes: No visual loss or blurred vision. Ears, Nose, Throat: No drainage, hearing loss, or sore throat.
SKIN: Warm, dry, no rash or itching.
CARDIOVASCULAR: No chest pain or discomfort.
RESPIRATORY: No coughing or shortness of breath.
GASTROINTESTINAL: No nausea, vomiting, or diarrhea
GENITOURINARY: No burning or discomfort on urination.
NEUROLOGICAL: Headache for 2 weeks, no numbness or tingling.
MUSCULOSKELETAL: No muscle or back pain.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Allergic to PCN, hx of asthma in childhood.
Physical exam: Vital signs- BP 120/70, HR-90, Temp- 98.2, RR-18, Wt-180, Ht-5’11.
General: JS is a 20 year old white male, A&O x4, in no apparent distress, calm and cooperative upon interview.
Head: Normal size and position, facial features symmetrical.
Eyes: Visual acuity 20/20 using Snellen chart, Eyes symmetrical, No nystagmus noted.
Neurological: Alert and oriented to person, place, time, and situation. Fluent in English language, thoughts and responses appropriate.
Diagnostic results:
CT scan- useful to detect intracranial disease
MRI- can detect any tumors or abnormalities
Lumbar puncture- Can be done in cases where CNS infection is suspected
- A.
Differential Diagnoses:
Tension headache- Most common type of headache, cause mild to moderate pain and come and go over time.
Migraine headache- often described as pounding, throbbing pain. They can last from 4 hours to 3 days and usually happen one to four times a month. Along with the pain, people have other symptoms, such as sensitivity to light, noise, or smells, nausea or vomiting, loss of appetite, and upset stomach.
Cluster headache- These headaches are the most severe. You could have intense burning or piercing pain behind or around one eye. It can be throbbing or constant.
Sinus headache- With sinus headaches, you feel a deep and constant pain in your cheekbones, forehead, or on the bridge of your nose.
Posttraumatic headaches- Occur 2-3 days after a head injury, and include trouble concentrating, vertigo, and memory problems.
References
https://www.webmd.com/migraines-headaches/migraines-headaches-basics#2
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
A Sample Answer 2 For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
JT, 20 y/o, Male, Caucasian
- Case 1: Headaches
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
CC: Pt c/o “headaches on and off throughout the day”
HPI: This is a 20 y/o Caucasian male who presents with a c/o severe h/a intermittently throughout the day. Pt states the pain begins at the crown of his head, continues above the eyes, travel to the nasal cavity, cheekbones and jaw area. Onset has been approximately one week with the pressure of the pain greatest above the eye. No n/v, no light sensitivity. Pt claims that pain is greatest when stressed at work in the day and will self medicate with Tylenol which makes the pain tolerable. Pt rates the pain as 8/10
Current Medications: Tylenol 650mg po q 6hr prn h/a.
Allergies: NKA
PMHx: Tdap 11/18/2019 negative for past surgical hx. Childhood asthma.
Soc Hx: Pt works as a computer technologist for a large company. Pt parents both smoke, pt smokes. Pt not interested in smoking cessation information at this time.
Fam Hx: Pt father has end stage COPD w/ chronic steroids usage and O2 dependant at 56y/o. Pt mother w/ hx of 2 pack per day cigarette habit, enphysema, migrains, CABG, NIDDM.
ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, no blurred vision. Ears, Nose, Throat: No hearing loss. No sneezing, positive for congestion, cough, sore throat and facial pressure noted.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, positive cough, no sputum production
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination.
NEUROLOGICAL: Localized headache w/ radiation to facial area. No dizziness syncope, paralysis, ataxia, numbness or tingling in the extremities.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: History of asthma, hives, eczema and rhinitis.
Vitals: B/P 143/71; Pulse 86; Temp 98.6; RR 20; O2 Sats 98% on RA; Wt 75kg
Physical exam:
General: Alert and oriented w/ some acute distress.
HEENT: Eyes: PEERLA. Ears, Nose, Throat: No hearing loss. No sneezing, positive for cough congestion core throat, post nasal drip. Facial pressure noted upon palpation (Inspecting the symmetry of the facial feature with various expressions is controlled by CN VII) (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
NEUROLOGICAL: Localized headache w/ radiation to facial area. No dizziness syncope, paralysis, ataxia, numbness or tingling in the extremities.
MUSCULOSKELETAL: No muscle, back pain, neck pain, joint pain or stiffness.
Diagnostic results: CBC-rule out sinus infection (Dains, Baumann, & Scheibel, 2016). CMP- asses renal function and electrolytes (Dains, Baumann, & Scheibel, 2016).CT head- noninvasive diagnostic tool used to detect intracranial disease (Dains, Baumann, & Scheibel, 2016).
- A.
Presumptive Diagnosis: Tension-Type Headache (TTH)
Differential Diagnoses
1. TTH: Can be bilateral, general or localized and characterized as frontotemporal distribution. Can be mild to moderate, throbbing tightness pressure lasting hours or days with frequent recurrences. Triggers can be related to stress, hunger or depression (Dains, Baumann, & Scheibel, 2016).
2. Migraine: Usually frontal or periorbital with rapid onset lasting for hours. Occurrences may be daily or weekly and common in adults 25-34 years of age. In fact, one study showed that asthma is associated with an increased risk for episodic migraine to chronic migraine (“Asthma Increases Risk for Migraine Chronification,” 2014). Mast cell degranulation or parasympathetic hyperactivity in asthma, can predispose a person to the future onset of chronic migraine (“Asthma Increases Risk for Migraine Chronification,” 2014). Another study states migraine patients have a higher risk of developing asthma.
3. Mixed Headache: A combination of vascular dysfunction and muscular contraction. Described as throbbing, tightness, pressure, and associated with familial history(Dains, Baumann, & Scheibel, 2016).
4. Sinusitis: Associated with facial pressure, sore throat, tooth pain, and sinus headache. Morning periorbital swelling, malaise, fever, and respiratory tract infection (Dains, Baumann, & Scheibel, 2016).
5. Dental Disorders: Severe headache and facial pain can be attributed to dental abscess, ulceration, infection, and sensitivity (Dains, Baumann, & Scheibel, 2016).
References
Asthma Increases Risk for Migraine Chronification. (2014, September). Retrieved from
https://www.mdedge.com/neurology/article/86796/headache-migraine/asthma-increases-
risk-migraine-chronification
Ball, J. W., Dains, J. E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s guide to
physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and
clinical diagnosis in primary care (5th ed.). St Louis, MO: Elsevier Mosby.
Hsieh, L. Y., Peng, Y. H., & Chia, H. L. (2016). MIGRAINE IS ASSOCIATED WITH AN INCREASED RISK OF ADULT-ONSET ASTHMA: A NATIONWIDE COHORT STUDY. Respiratory Care, 61(10).
A Sample Answer 3 For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
R.H., 33, Female, Caucasian
CC: Sudden “drooping,” excessive tearing, and drooling on right side of face.
HPI: R.H. is a 33-year-old Caucasian female who presents to the clinic today with complaints of sudden “drooping” on the right side of her face. Associated signs and symptoms include excessive tearing and drooling on the right side of her face. Symptoms began suddenly this morning. She is experiencing no pain, 0/10, but is experiencing numbness on the right side of her face. She is alarmed and unsure what is going on. She has tried nothing to relieve her symptoms and has not noticed anything that makes it worse.
Current Medications:
1.) Ibuprofen 400mg PO q6 hrs PRN for pain
2.) Multivitamin PO once daily in am
Allergies:
NKA
PMH
1.) Generalized anxiety
2.) Headaches
PSH
1.) Appendectomy 1994
Sexual/Reproductive History:
Heterosexual
1-1-0-0-1
Social Hx:
Negative for current or past tobacco or illicit drug use. Drinks alcohol socially in moderation.
Immunization History: Up-to-date
Tetanus(Tdap): 2016
Influenza: 11/2018
Family Hx:
Mother, alive, age 62, hx overweight
Father, alive, age 59, hx chronic low back pain
Maternal Grandmother, deceased age 71, stroke, hx osteoporosis, dementia
Maternal Grandfather, deceased at age 69, MI, hx DM type 2
Paternal Grandmother, alive, age 101, hx cataracts, HTN, dementia, GI bleed
Paternal Grandfather, deceased at age 73, kidney failure, hx CKD
Brother, alive, 36, prehypertension
Lifestyle:
Patient is a self-employed event planner, married for 5 years with 1 dependent child age 1.5 years. Has support of husband, family, and friends. Diet is well-balanced, home cooked, consisting of three meals daily, and exercises 30-60 minutes 3-4 times a week. Has health insurance through her husband’s employer. Had annual examination with primary care provider approximately 6 months ago.
ROS:
General: No weakness or night sweats. No recent weight gain or loss of significance. Denies recent illness, fever, chills, or feeling fatigued.
HEENT: No history of head injury. No corrective lenses. Denies visual changes, diplopia, floaters, or photophobia. Reports recent excessive tearing. Denies any hearing difficulties or loss of hearing. Denies tinnitus, vertigo, infections, or nasal drainage. Denies any change in sense of smell. Denies any episodes of epistaxis, nasal polyps, or recent sinus infection. Denies bleeding gums; cavities that have been filled. Reports good oral care, last dental visit was 4 months ago. Reports recent drooping of right side of face with drooling on right side. Reports difficulty eating, drinking, and forming some words since facial drooping began.
Neck: Denies lumps, swollen glands, pain, or stiffness.
Breasts: Denies lumps, pain, changes in color or texture of skin, or nipple discharge.
Respiratory: Denies cough, shortness of breath, or night sweats.
Cardiovascular: Denies chest pain, pressure, palpitations, or orthopnea.
Gastrointestinal: Denies nausea, vomiting, diarrhea, or constipation. No melena or hematochezia. No pain, appetite is good. No known liver problems or gallbladder problems.
Genitourinary: No frequency, urgency, dysuria, hematuria, incontinence, flank pain, or dyspareunia. Annual physical examination completed 7/2018.
Peripheral vascular: Denies varicose veins, edema, phlebitis, leg pain, cyanosis, numbness or tingling in extremities.
Musculoskeletal: Denies any weakness, pain, joint swelling, or arthritis. Denies recent fall or trauma.
Integumentary: No rash or itching. Denies dermatitis or psoriasis.
Psychiatric: Reports generalized anxiety, no other history of psychiatric disorders. No thoughts of self-harm. Denies depression.
Neurologic: Denies headache, seizures, syncope, stumbling, changes in balance or coordination, or changes in memory. Reports drooping and numbness to right side of face. Reports difficulty eating, drinking, and speaking.
Hematologic: Denies anemia, bleeding, bruising, or history of clotting disorders. No history of blood transfusion.
Endocrine: No night sweats, cold or heat intolerance, polyuria. No excessive thirst or hunger.
Allergic/Immunologic: Denies asthma, eczema, or rhinitis. No known immune deficiencies.
Physical Examination
Vital signs:
BP: 126/72, right arm, sitting; HR: 76, regular; RR: 16, regular; T: 98.2 degrees F, tympanic; SpO2: 98% RA; W: 132 pounds, stable; Ht: 5’3”; BMI: 23.4
General Appearance: Alert and oriented x3, cooperative. Answers appropriately but with some speech difficulty. Patient appears to be worried and anxious but in no acute distress. Well-groomed, appropriately dressed.
HEENT: Hair of average texture. Scalp without lesions, normocephalic/atraumatic. Conjunctiva pink; sclera white. Pupils equal, round, regular, reactive to light. Extraocular movements intact. Right eyelid unable to close completely, sag to right lower lid, excessive tearing noted. Tympanic membranes visualized, clear canal and good cone of light, bilaterally. Acuity good to whispered voice. Mucosa pink, septum midline. Oral mucosa pink. Good dentition. Tongue midline, pink, and moist. Tonsils absent. Pharynx without exudates.
Neck: Trachea midline, supple, no palpable nodes
Lymph nodes: No lymphadenopathy in any nodes. No palpable cervical, axillary or epitrochlear nodes. Small inguinal nodes bilaterally, soft and nontender.
Chest: Heart rate regular with normal S1, S2; no S3, S4. No murmurs, rubs, and gallops.
Lungs: Lung expansion symmetrical, regular and non-labored, CTA without rales, wheezes or rhonchi.
Peripheral vascular: No pedal edema; 2+ dorsalis pedis pulses bilaterally, capillary refill less than 3 seconds.
Musculoskeletal: No obvious deformities, masses, discoloration, or enlarged joints. No musculoskeletal pain or limitation in ROM. Gait steady, able to move extremities appropriately.
Neurologic Mental Status: Awake, alert and oriented to person, place, and time. Cooperative. Deep tendon reflexes 2+lower extremity. Impaired speech. Facial sensation intact. Drooling noted to right side of mouth. Unable to wrinkle forehead, limited ability to close right eye or grimace.
Skin: Warm, moist, pale. Intact without lesions, rashes, or urticaria.
Diagnostics:
Diagnosis of Bell’s Palsy is typically based on clinical presentation (Hollier & Hensley, 2011).
CT – rule out stroke or neoplasm
Electromyographic (EMG) testing – determine severity and extend of nerve involvement
Lyme titer – if history of tick bite
(Hollier & Hensley, 2011).
MRI – if other neurological deficits are present, exclude other structure causes
Serum ACE – check for sarcoidosis
(Rubin, 2017).
Assessment:
DDx:
1. Bell’s Palsy (primary dx)
- Sudden onset of symptoms
- Paralysis on one side of face
- Numbness to affected side
- Drooping to corner of mouth on affected side
- Drooling
- Excessive tearing
- Impaired speech
- Difficulty eating or drinking
(Hollier & Hensley, 2011).
- Limited ability to wrinkle forehead or grimace
(Rubin, 2017).
2. Stroke
- Sudden onset
- Numbness or weakness to one side of body
- Difficult speech
- Difficult management of secretions
- Weakness or paralysis of facial muscles on one side of body
(Dains, Bauman, & Scheibel, 2016).
3. Myasthenia Gravis
- Droop to eyelid
- Difficulty swallowing or speaking
- Difficult management of secretions
- Ptosis
(Dains, Bauman, & Scheibel, 2016).
4. Neurosyphilis
- Hemiplegia
- Focal neurological deficits
(Dains, Bauman, & Scheibel, 2016).
5. Transient Ischemic Attack (TIA)
- Sudden onset
- Dysphagia
- Dysarthria
- Unilateral weakness
(Hollier & Hensley, 2011).
References
Dains, J., Bauman, L., Scheibel, P. (2016). Advanced health assessment and clinical
diagnosis in primary care (5th ed.). St. Louis: Missouri: Elsevier.
Hollier, A., & Hensley, R. (2011). Clinical Guidelines in Primary Care: A Reference and
Review Book. Layfayette, LA: Advanced Practice Education Associated, Inc.
Rubin, M. (2017). Facial nerve palsy. Merck Manual. Retrieved from
https://www.merckmanuals.com/professional/neurologic-disorders/neuro-ophthalmologic
A Sample Answer 4 For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
M.J., 47, F, Hispanic
CC: “pain in the right wrist”
HPI: 47-year-old Hispanic female presents with pain in her right wrist with tingling and numbness in the thumb, index and middle fingers which began 2 weeks ago.
Additional questions: How would you describe the pain? Is there a time of day or night when the pain is experienced? Any exacerbating or relieving factors? On a scale of 1 to 10, how severe is the pain? Do your symptoms spare the little finger? Are your symptoms made worse by activities such as driving, holding a telephone, using vibrating tools, or typing? (Burton, Chesterton, & Davenport, 2014)
Current Medications: Levothyroxine 88mcg
Allergies: codeine – hives
PMHx: Tetanus vaccine 2010, all other immunizations are current, hypothyroidism, myomectomy 2016, hysterectomy 2018.
Soc Hx: owner and operator of a unisex hair salon, married for 20 years with 4 children. No tobacco, alcohol or recreational drug use. She admits to regular seat belts use, increasing physical activity to lose weight and healthier eating habits.
Fam Hx: mother has hypertension and hyperlipidemia, the father has hyperlipidemia, maternal grandparents are healthy, paternal grandmother hypertension, paternal grandfather has glaucoma. The older sister has hyperlipidemia, younger brother and sister are healthy.
ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or a sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning with urination. Menopausal.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, or ataxia. Positive for numbness and tingling in right wrist thumb, index and middle fingers. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Vital signs: T 98.7, BP 129/ 67, HR 72, RR 19, 98% RA, 5’5”, 185lbs., BMI 30.8.
General: Healthy appearing female with good posture, clean hygiene, answers questions appropriately and makes eye contact while speaking.
HEENT: The head is normocephalic, hair evenly distributed, PERRLA, EOMI, ear canals patent, bilateral TM pearly gray with positive light reflex, nasal mucosa pink and moist, no septal deviation, the pharynx is non-erythematous and clear, teeth are in good condition
Peripheral Vascular: 2+ pulses, extremities warm and appropriate color, no edema
Neurological: Good posture, stable gait. Square-shaped wrist, hypalgesia on the palmar aspect of the index finger, inability to distinguish between two points, weakness of thumb abduction (Wipperman & Goerl, 2016).
Additional physical exam and diagnostics: The hand elevation test, Phalen maneuver, Tinel sign, nerve conduction studies and electromyography (Wipperman & Goerl, 2016). The onset of symptoms during these tests is a positive result for carpal tunnel syndrome.
- A.
Differential Diagnoses:
- Carpal Tunnel Syndrome: Patients present with numbness, tingling, pain, and aching in the thumb, index and middle fingers. Women have a higher prevalence of carpal tunnel syndrome and obesity and hypothyroidism are associated with CTS (Burton, Chesterton, & Davenport, 2016).
- Cervical radiculopathy: Patients present with neck or arm pain, sensory deficits, motor deficits, and diminished reflexes. A diagnosis is made using a Spurling test, shoulder abduction test, Valsalva maneuver, neck distraction, and Elveys upper limb tension test along with imaging to confirm compression of the cervical nerve roots (Iyer & Kim, 2016).
- Neuralgic amyotrophy: Patients will present a sudden onset of aching, burning, or stabbing pain in the shoulders, neck or arm with weakness in the periscapular and periglenohumeral muscles with pain worse at night. Diagnosis is based on clinical symptoms, the exclusion of other disorders and confirmed with molecular genetic testing (orpha.net, 2013).
- Brachial plexus injury: Patients will present with tenderness over the suprascapular notch, muscle weakness during shoulder abduction and external rotation, and pain in an upper limb. A diagnosis is confirmed with imaging studies such as a CT, CT myelography or MRI (Sakellariou, Badilas, Mazis, Stavropoulos, Kotoulas, Kyriakopoulos, Tagkalegkas, & Sofianos, 2014).
- Cervical syringomyelia: Patients present with motor weakness, sensory disturbances, pain and even bladder disturbances in some cases as a result of a spinal cord injury. The diagnosis is confirmed with imaging studies such as MRI (Kim, Oh, Kim, & Park, 2014).
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Burton, C., Chesterton, L. S., & Davenport, G. (2014). Diagnosing and managing carpal tunnel syndrome in primary care. Br J Gen Pract, 64(622), 262-263. doi: 10.3399/bjgp14X679903
Burton, C., Chesterton, L. S., & Davenport, G. (2016). A painful tingling hand. BMJ, 355, i6386. doi: https://doi.org/10.1136/bmj.i6386
Iyer, S., & Kim, H. J. (2016). Cervical radiculopathy. Current reviews in musculoskeletal medicine, 9(3), 272-280. doi: 10.1007/s12178-016-9349-4
Kim, H. G., Oh, H. S., Kim, T. W., & Park, K. H. (2014). Clinical features of post-traumatic syringomyelia. Korean journal of neurotrauma, 10(2), 66-69. doi: 10.13004/kjnt.2014.10.2.66
Orpha.net. (2013). Neuralgic amyotrophy. Retrieved from https://www.orpha.net/consor/cgi-bin/OC_Exp.php?Expert=2901
Sakellariou, V. I., Badilas, N. K., Mazis, G. A., Stavropoulos, N. A., Kotoulas, H. K., Kyriakopoulos, S., … & Sofianos, I. P. (2014). Brachial plexus injuries in adults: evaluation and diagnostic approach. ISRN orthopedics, 2014. doi: 10.1155/2014/726103
Wipperman, J., & Goerl, K. (2016). Carpal Tunnel Syndrome: Diagnosis and Management. American family physician, 94(12). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28075090
A Sample Answer 5 For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
A.B., 20yr old, M, AA
CC (chief complaint)” headaches”
HPI: 20-year-old AA male c/o of intermittent headaches that started a week ago. The pain is generally all over his head, but the pain is mostly and severe above his eyes. The pain radiates to his nose, cheekbones, and jaw. When the pain is at it worse, lights make it worse. Sleep and sinus medicine, like Tylenol sinus and headache medicine, make it better. The patient describes the pain as pressure and nagging that comes and goes. He notices when he is at work, the pain starts. On the pain scale, the pain is at 6/10.
Current Medications: OTC Tylenol sinus and headache 2 tablets every 6 hours for a headache, multivitamin 1 tab daily for wellbeing, and drinks a protein shake every morning.
Allergies: No Known Allergies.
PMHx: up-to-date on all immunizations, received flu shot 10/2018. No history of surgeries. Only had a cold that lasted for 3 days two weeks ago.
Soc Hx: Pt just started a lawn business a month ago with his father and brothers. Enjoys playing sports with friends and his two brothers. Denies smoking, alcohol, and recreational drug usage. Lives with his father and two young brothers age 14 and 16. Pt states that he always uses a seatbelt while in a motor vehicle. The patient states that he is sexually active and uses a condom. The family lives in a gated community in a two-story single-family home. Denies texting and driving. States that he uses Bluetooth to talk on his cell phone while driving.
Fam Hx: parents are divorced. Mother age 40 years old is healthy with no known illness and works in Dubai as a traveling nurse. Father 42 years old is healthy with no known illness, works with sons in family-owned lawn company. Grandparents (paternal) lives in the surrounding neighborhood. Grandfather dx with CHF 1yr ago. Grandmother dx with COPD; previous smoker, quit 6 months ago. Grandparents (maternal) lives out the country, unknown medical history. Two brothers age 14 and 16 both are healthy.
ROS
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision. Slight red sclerae itching, and watery. Pressure above the eyes. Ears, Nose, Throat: No hearing loss, positive for sneezing, positive for congestion, positive for a runny nose and neg for a sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: positive for a headache, denies dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Pain in the cheekbones and jaw. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Physical exam: Temp 98.6, B/P 120/60, Pulse 80, Resp 20. Able to move head and neck from side to side and up and down. Pt can smile and stick out his tongue without any difficulty. Pt can swallow without choking. Skull, on palpation, is non-tender, symmetrical and smooth. Scalp moves freely, no swelling is noted. Pt can move jaw c/o of some pain. Pain is felt of top of eyes when palpating. Pupils are equal, round, reactive to light. Optic disk is pink with sharp margins. Retina intact. No hemorrhages noted. On palpation of maxillary sinuses, patient c/o of tenderness. Tympanic membranes in bilateral ears are intact with minimal cerumen. No perforation is noted. Inspection of the nasal cavity, green mucus is seen. Nose septum intact, no deviation noted.
Diagnostic results: CT scan of the sinuses. CT scan will give a detailed image of the sinuses and possible help distinguished between chronic and acute sinusitis (WebMD, 2018). Rhinoscopy. A procedure that can be done in the office to evaluate for nasal obstruction, sinusitis, epistaxis, anosmia, other symptoms of rhinitis, and head and neck cancer (Adil MD, 2018). Skin testing for allergies. Skin allergies testing helps determine what an individual is allergic to avoid an allergic reaction. An extract is used from common allergens, such as pollen, mold, dust mites, animal dander, and foods is placed under the skin to get a reaction. If a reaction occurs, the individual will develop a rash and his or her immune system will make antibodies and set off chemicals to fight off the trigger (WebMD, 2018).
- A.
Differential Diagnoses 1. Acute sinusitis. Acute sinusitis is most commonly due to a cold-causing viral infection (Kivi, 2017). Sign and symptoms include stuffy nose, pressure on cheekbones, headache, and eye pressure (Kivi, 2017). Intranasal allergies may cause acute sinusitis.
- Migraine. Migraines are a recurring type of headache that causes moderate to severe pain that is throbbing or pulsing ( National Institute of Neurological Disorders and Stroke, 2019). Increased sensitivity to light, noise, and odors are some common symptoms ( National Institute of Neurological Disorders and Stroke, 2019).
- Allergic rhinitis. Also known as hay fever, develops when the body’s immune system becomes sensitized and overreacts to something in the environment that typically causes no problems in most people (Allergist, 2018). In the spring, the most common triggers are grass and tree pollen (Allergist, 2018). Symptoms include sneezing, congestion, coughing, sinus pressure, itchy watery eyes, and itchy nose, mouth, and throat, and fatigue (Allergist, 2018). A headache, purulent discharge, and facial pain/pressure are less common (Epocrates, 2019).
- Nonallergic rhinitis. A heterogeneous group of nasal diseases that has nasal obstruction or rhinorrhea as common factors (Epocrates, 2019).
- Cluster headache. A cluster headache typically manifests as minutes to hours of severe unilateral temporal headache that occurs in grouped attacks over a period of weeks to months and is associated with periorbital pain and rhinorrhea (RavalMD, 2019)
Reference
National Institute of Neurological Disorders and Stroke. (2019, January 8). Migraine. Retrieved from U.S. National Library of Medicine: https://medlineplus.gov/migraine.html.
AdilMD, E. A. (2018, December 18). Flexible Rhinoscopy. Retrieved from Medscape: https://emedicine.medscape.com/article/1890801-overview.
Allergist. (2018, February 6). Allergic Rhinitis. Retrieved from American College of Allergy, Asthma, and Immunology: https://acaai.org/allergies/types/hay-fever-rhinitis.
Epocrates. (2019). Acute sinusitis. Retrieved from Epocrates: https://online.epocrates.com/diseases/1435/Acute-sinusitis/Differential-Diagnosis.
Kivi, R. (2017, December 14). Acute Sinusitis. Retrieved from Healthline: https://www.healthline.com/health/acute-sinusitis.
RavalMD, T. (2019, January 19). Facial Pain and Headache. Retrieved from Medscape: https://emedicine.medscape.com/article/1048596-overview#a4.
WebMD. (2018, May 26). Picture of the Sinuses. Retrieved from WebMD: https://www.webmd.com/allergies/picture-of-the-sinuses#2.
A Sample Answer 6 For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
HS, 20 years old, Male, Hispanic
CC: “I keep getting these headaches.”
HPI: The patient is a 20-year-old Hispanic male who presents with intermittent headaches that started two weeks ago. The patient describes the pain as a dull pressure that occurs all over his head, with the most significant pain and pressure occurring above his eyes, spreading to his nose, jaw, and cheekbone. Stated headaches occur throughout the day and could not pinpoint anything that makes them worse. The patient stated rest and Tylenol makes his symptoms better. Stated he had tried Tylenol and cold compresses with relief in his pain. The patient rates his pain a 5/10 at its worst.
Current Medications: Tylenol 650 mg every six hours as needed for pain and a multivitamin daily.
Allergies: Penicillin-rash.
PMHx: Denies any previous hospitalizations or surgeries. Stated had tension headaches during his fifth-grade year. Stated immunizations are up to date; the last influenza vaccine was 11/2018, and last TDAP was 03/2018. Stated received all childhood immunizations.
Soc Hx: Single, fulltime college student that is studying chemical engineering. Negative for alcohol, tobacco, excessive caffeine intake, or illicit drug use. He has denied exposure to any toxins or carbon monoxide. The patient stated he has been under more stress lately with upcoming midterm exams.
Fam Hx: Mother age 44-living, cluster headaches diagnosed at age 16. Father age 45-living and healthy. No siblings or children. Stated unknown health history of grandparents.
ROS:
General: Denied any fever, chills, malaise, fatigue, night sweats, change in appetite, or weight loss.
HEENT: See HPI. Denied any vision changes, double vision, trauma, light sensitivity, or eye disease. Denied any head injuries, loss of consciousness, or dizziness. Denied any hearing loss, vertigo, tinnitus, or ear discharge. Denied any nasal congestion, nosebleeds, or postnasal drip. Denied any hoarseness, sore throat, bleeding gums, or tooth problems.
Gastrointestinal: Denied any nausea, constipation, diarrhea, or vomiting.
Musculoskeletal: Denied any joint pain, heat, or swelling.
Neurologic: Denied any changes in gait, loss of coordination, weakness, or fainting.
Mental Status: Denied any changes in concentration, trouble sleeping, eating, mood changes, suicidal ideation, or with socialization. States has been under more stress lately.
VS: B/P 116/65; P 65; R 1; T 98.7; O2 100% RA; Wt: 165lbs; Ht 69”
Physical exam:
General: A&O x3, in no acute distress, walks with a steady gait to the exam table
Head and Neck: Negative for scalp tenderness, lesions, and scalp is symmetrical. Temporal arteries were palpable, not bounding or weak and with some tenderness noted upon palpation. No cranial bruits noted. No stiffness or limited ROM noted of the neck.
EENT: Pupils are equal, round, and reactive. Optic disc was round and creamy pink, no atrophy noted. No optic nerve swelling noted, hemorrhages, or microaneurysms. EOMs are not tender, and no issues noted upon exam. External ear canals were clear and free of discharge, redness, or lesions. Bilateral tympanic membranes were translucent, pearly gray, non-bulging, and light reflex was noted. No swelling or redness noted of nasal mucosa or turbinates. No nasal discharged noted. No sores or lesions noted of the oral mucosa. No broken teeth or poor dentation noted.
Neurological: Cranial Nerve function intact for nerves I, II, III, IV, VI, V, VII, VIII, IX, X, and XII. No issues with motor strength or coordination of extremities noted. Deep tendon reflexes are present and not hyperactive.
Diagnostic results: No diagnostic imaging or lab work was indicated according to Dains, Baumann, and Scheibel (2016) as the patient did not present with any physical findings of a possible infection, abnormal neurological signs, sudden onset of a severe headache, or head trauma (Dains et al., 2016).
- A.
Differential Diagnoses
1) Tension Headache-Patients with tension headaches may present with bilateral pain that is mild to moderate and does not throb (Taylor, Swanson, & Dashe, 2018). According to Taylor et al. (2018), there are not any specific diagnostic tests for diagnosing tension headaches, and a diagnosis is typically made by completing a physical exam and patient history.
2) Cluster Headache-Patients with cluster headaches can present with five to eight episodes a day of unilateral pain that includes eye pain, eyelid swelling, nasal congestion, rhinorrhea, temporal pain, sweating of the forehead or face, ptosis, agitation, and restlessness (May, Swanson, & Dashe, 2018). Diagnosis is typically made through a physical exam, completing a patient history and the diagnostic criteria for cluster headaches (May et al., 2018).
3) Migraine-Patients with migraine headaches may complain of nausea and vomiting, visual aura before a migraine, photophobia, and vertigo, with a unilateral frontal or periorbital throbbing headache (Dains et al., 2016). Patients may also experience numbness, aphasia, weakness, and noise and light sensitivity (Dains et al., 2016). One to two days before a migraine occurs patients may experience an increase in thirst and urination, neck stiffness, frequent yawning, constipation, food cravings, and mood changes (Mayo Foundation for Medical Education and Research, 2019). A diagnosis is typically made through a physical exam and patient history (Dains et al., 2016).
4) Mixed Headache-According to Dains et al. (2016) patients with a mixed headache may present with a throbbing headache that is constant with muscle tightness. A mixed headache can present with symptoms of a tension headache and a migraine headache (Dains et al., 2016).
5) Sinusitis-Symptoms of sinusitis involves a headache over the sinus that is infected along with pain in the face or teeth, postnasal drainage, cough, increased pain with bending forward, periorbital swelling, malaise, pain upon palpation of the sinuses, or fever (Dains et al., 2016). A diagnosis is typically made by a physical examination, patient history, and radiograph imaging if indicated (Dains et al., 2016).
Primary Diagnosis/Presumptive Diagnosis: Tension Headaches
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
May, A., Swanson, J.W., & Dashe, J.F. (2018). Cluster headache: Epidemiology, clinical features, and diagnosis. UpToDate. Retrieved from https://www.uptodate.com/contents/cluster-headache-epidemiology-clinical-features-and-diagnosis?search=cluster%20headache&source=search_result&selectedTitle=1~43&usage_type=default&display_rank=1
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Mayo Foundation for Medical Education and Research (MFMER). (2019). Migraine. Retrieved from https://www.mayoclinic.org/diseases-conditions/migraine-headache/diagnosis-treatment/drc-20360207
Taylor, F.R., Swanson, J.W., & Dashe, J.F. (2018). Tension-type headache in adults: Pathophysiology, clinical feature, and diagnosis. UpToDate. Retrieved from https://www.uptodate.com/contents/tension-type-headache-in-adults-pathophysiology-clinical-features-and-diagnosis?search=tension%20headache&source=search_result&selectedTitle=2~73&usage_type=default&display_rank=2
A Sample Answer 7 For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Case #1 Headaches
Focused SOAP Note for a patient with headaches
Subjective
Chief Complaint: “These headaches keep coming back no matter what I do ”.
History of Present Illness: H.A is a pleasant, alert and oriented Caucasian 20-year-old male who has been experiencing intermittent headaches for three weeks. He reports that when. Patient states that The patient has tried Excedrin since the incident, but it has not been successful in alleviating his symptoms.
Medications:
Zyrtec I tab daily prn
Excedrin 2 tablets Q6H prn
Previous Medical History: Pt has a history of seasonal allergies.
Significant Family History: Mother just turned 40 and does not take any medications or have a medical history to his knowledge. Father has a history of hypertension, and diabetes which are both controlled by medications. Maternal grandparents are still living, grandfather is recovering from bypass surgery and grandmother is well with a history of depression and Crohn’s disease. Paternal grandparents are alive as well. Grandmother has hypothyroid and hypertension but is very active and grandfather is well, takes medication psoriasis and psoriatic arthritis.
Social History: Pt denies tobacco or illicit drug use, but does report social alcohol intake and states his favorite drinks are Monster Energy drinks and drinks at least three a day. Pt is an undergraduate student studying engineering at the local university. He lives off campus with two friends that he has known since childhood. He has a girlfriend of three years and plans on getting married once he completes his baccalaureate degree in the spring. His mother is not on board with his impending marriage, which causes strain with his concentration on school and relationship with fiancé. He reports his dad is best friend that will “always have his back, no matter what”. His hobbies include hiking, playing basketball with his buddies, and tailgating on the weekends.
Review of Symptoms
General: Negative for fevers, chills, no change in weight or appetite.
HEENT: Pt denies any itchy nose, eyes, and ears or nasal congestion. Intermittent headaches reported.
Cardiovascular: Patient denies palpitations, chest pain, extremity edema
Gastrointestinal: No compliant of nausea today but reports he experiences it when pain is bad, no vomiting, diarrhea, or abdominal pain.
Pulmonary: Patient denies any dyspnea with or without exertion.
Musculoskeletal: Patient reports headache, eye, and jaw pain
Neurological: Patient denies any problems with her gait, loss of coordination, falls, or seizures.
Psychological: Reports stressful periods of sue to his academic studies and familial relationships
Allergic/Immunologic: He has seasonal allergies. No other allergies to medications, foods, or substances.
Objective
Vital Signs: 97.6F; BP 148/93; HR 83; RR 18; O2 sats 99%
Pain -8/10
General: Patient is alert and oriented x 4, appears to be in pain but appears to be well groomed and nourished.
HEENT: . Patient has slight tenderness with palpation and percussion of facial structures, congestion, or throat irritation or pain
Cardiovascular: Patient is negative for murmurs, palpitations, chest pain, extremity edema
Gastrointestinal: The abdomen is without distention; bowel sounds are present and active in all four quadrants, no abdominal masses, or tenderness noted
Pulmonary: Lungs are clear to auscultation. Crackles or significant consolidation is not noted
Musculoskeletal: no decrease noted in range of motion
Neurological; patient is able to bear weight without difficulty and gait is unremarkable.
Psychological: patient appears to be appropriate. Suicide screening completed was negative.
Diagnostic results:
- Physical Exam
- CT or MRI – dependent on the severity of the findings of the x-ray and other testing
(Dains, Baumann, Scheibel, 2016)
Assessment
Primary/Priority Diagnosis:
Medication Rebound Headache: this types of headache is usually from a person taking a certain type of medication to treat another a common headache or other ailment but takes too frequently (Kristofferson & Lundqvist, 2014). In this case, the patient admits that his intake of monster energy drinks in addition to taking Excedrin, which contains caffeine and acetaminophen, and aspirin.
Differential Diagnosis:
Tension headache: this type of headache is usually the result of a person experiencing emotional strife, being tired, or joint or muscular problems with the neck, or jaw area. These types of headaches produce dull headaches with a squeezing that can be bothersome (Harvard Heath, 2019). These types of headaches can become chronic nature where follow up diagnostics are required such at CT and/or MRI
Acute Sinusitis/Rhinosinusitis: Allergies or the common cold can start this condition which produces headache, different areas of facial pain such as the frontal and maxillary sinus, periorbital and molar areas (Dains et al., 2016). This is from the accumulation of nasal fluids (Dains et al., 2016).
Migraine without Aura: is a known to be the common type of migraine in younger patients such as H.A. or younger children (Dains et al., 2016). Patients usually experience nausea and vomiting, and throbbing pain associated with the these style of advanced headaches and many times are triggered by stress, which H.A. mentioned he has currently has stress with his relationship with his mother and from his studies.
Trigeminal Neuralgia: is an episodic type of condition which is results in several “attacks” daily (National Organization for Rare Disorders, 2018). This disorder is known for its dull heaches and jaw pain and in some cases upper facial pain (Dains et al., 2016). Most people affected are usually female and 55 years or older but in cases where it has affected younger patients, it is usually an indicative of having multiple sclerosis (Dains et al., 2016).
References
Dains, J. E., Baumann, L. C., Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Harvard Health. (2019). Tension Headaches. Retrieved from https://www.health.harvard.edu/pain/headache-when-to-worry-what-to-do
Kristoffersen, E. S., & Lundqvist, C. (2014). Medication-overuse headache: epidemiology, diagnosis and treatment. Therapeutic advances in drug safety, 5(2), 87-99.
National Organization for Rare Disorders. (2018). Trigeminal Neuralgia. Retrieved from https://rarediseases.org/rare-diseases/trigeminal-neuralgia/